Provider Demographics
NPI:1003836313
Name:LOVELL, RANDY J (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:J
Last Name:LOVELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:THOMPSON FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59873-0969
Mailing Address - Country:US
Mailing Address - Phone:406-827-4307
Mailing Address - Fax:406-827-9514
Practice Address - Street 1:907 MAIN ST
Practice Address - Street 2:
Practice Address - City:THOMPSON FALLS
Practice Address - State:MT
Practice Address - Zip Code:59873
Practice Address - Country:US
Practice Address - Phone:406-827-4307
Practice Address - Fax:406-827-9514
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6022207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000093800OtherBC & BS
38520OtherTRIWEST
MT0056238Medicaid
38520OtherTRIWEST
000008400Medicare PIN
C64249Medicare UPIN
000083258Medicare ID - Type Unspecified